Penetrating injury to the gluteal region

Isolated penetrating gluteal stab injury with uncontrolled bleeding in Türkiye: a case report

Arterial injuries in the gluteal region caused by a knife are rare but serious, with mortality rates of up to 25%. This case report presents the management of a young male patient admitted to the emergency department in hypovolemic shock, with uncontrollable bleeding from an isolated penetrating gluteal injury. Additionally, the details of the surgical approach employed are discussed.

Penetrating buttock trauma is morbid but rarely fatal - A South African experience

BACKGROUND

Penetrating injuries to the buttock are relatively rare but are associated with significant morbidity. This study aimed to review our experience in managing penetrating trauma to the buttocks to contextualize the injury, document the most common associated injuries, and generate an algorithm to assist with the management of these patients.

METHODS

A retrospective study was conducted at a major trauma center in South Africa over 8 years (January 2012 to January 2020). All patients presenting with a penetrating buttock injury were included.

RESULTS

Our study included 40 patients. Gunshot wounds accounted for 93% (37/40), stab wounds accounted for 5% (2/40), and 1 case was gored by a cow. The majority (98%) underwent further investigation in the form of imaging or endoscopy. Forty percent (16/40) required surgical intervention. Of these 16 cases, 14 required a laparotomy, and 2 required gluteal exploration. Fifty-six percent (9/16) required a stoma. Five percent (2/40) experienced one or more complications, both of whom had stomas. The median length of stay for all patients was 3 days, whereas for the patients with stomas was 7 days. There were no ICU admissions or mortality in this study. Only 3 of the 9 stomas were reversed, and the median time to reversal was 16 months.

CONCLUSION

Penetrating trauma to the buttock may result in injuries to surrounding vital structures, which must be actively excluded. Rectal injury was the most common injury, and most required a defunctioning colostomy as part of the management resulting in significant morbidity.

Hybrid Management of a Pseudoaneurysm of the Inferior Gluteal Artery Following a Stab Wound

Aneurysms and pseudoaneurysms of the gluteal artery are rare. They represent less than 1% of the described arterial aneurysms. Those that touch the inferior gluteal artery are even rarer. Only a few cases have been described worldwide. Such cases often present with a variable time course, mode of injury, and associated symptoms, leading to their misdiagnosis and improper treatment. We present the case of a 30-year-old male, who presented to our emergency room one week after a stab wound in the left gluteal region causing a pseudoaneurysm of the left inferior gluteal artery with a sciatic compartment syndrome treated by a hybrid approach.

Superior gluteal artery pseudoaneurysm after a gunshot wound to the buttock: A case

•

Gunshot and stab wounds are common causes of penetrating trauma to the buttock.

•

Penetrating trauma to the upper zone of the buttock can result in vascular injury.

•

Pseudoaneurysms are rare complications of traumatic arterial injuries.

•

Pseudoaneurysms can be treated with embolization.

•

There are no guidelines for screening of gluteal pseudoaneurysms after trauma.

Introduction

Penetrating trauma to the buttock can rarely result into the development of a gluteal artery pseudoaneurysm. Here we present the case of a patient with a superior gluteal pseudoaneurysm after a gunshot wound to the left buttock.

Presentation of case

A 48-year-old male presented with fullness and tenderness at the left gluteal wound that resulted from a gunshot 18 days prior. At the time of initial trauma, imaging showed minimal extravasation of contrast at the left superior gluteal artery, but the bleeding stopped and patient was discharged. On his return, examination showed palpable fluctuance but no bleeding. A superior gluteal artery pseudoaneurysm was identified on CT scan. Patient also complained of intermittent subjective fever and new onset of SOB. CT chest demonstrated a pulmonary embolism at the right basilar segmental artery. Coil embolization was performed to treat the pseudoaneurysm and patient was subsequently started on anticoagulation therapy.

Discussion

Penetrating wounds to the buttock can result in associated vascular or visceral injuries. Pseudoaneurysms can develop days to years after the initial injury. On exam, presence of pain, swelling, tenderness, bleeding from wound, thrill, bruit or a pulsating mass should raise suspicion for pseudoaneurysm, which can be diagnosed on CT scan and treated with embolization.

Conclusion

Proper management of traumatic wounds to the buttock with associated vascular injuries, with follow up protocols and patient education is necessary to prevent life-threatening complications such as hemorrhage from pseudoaneurysm.

Delayed presentation of superficial femoral artery pseudoaneurysm 45 years following gunshot injury

This case report is a description of an uncommon delayed presentation of penetrating trauma of lower limb with history of inciting event being 45 years ago, as there are only 4 such reported cases in the literature. A 65-year-old male presented with progressive enlargement of swelling over the anterior aspect of the right thigh with difficulty in walking due to mechanical effects and paraesthesia in the affected limb. Clinical signs of a large lump in the right anteromedial thigh with no pulsations were present. Computerised tomographic angiography revealed the presence of a superficial femoral artery pseudoaneurysm. The open surgical management involved resection of the pseudoaneurysm and autologous vein patch angioplasty. The rarity of incidence and paucity of physical signs suggest that a high index of suspicion, careful clinical review and radiological investigation is indispensable to diagnose and treat this condition.

A Rare Case of Superior Gluteal Artery Pseudo Aneurysm after Blunt Trauma

Prevailing over in rotationally unstable pelvic fractures, acetabular fractures or hip dislocations, superior gluteal artery pseudo aneurysm imperceptibly could be found after blunt force trauma of the pelvic region. We present a case of superior gluteal artery pseudo aneurysm after blunt force trauma that became gradually symptomatic in two months following the prime malevolence. Non-resolving gluteal hematoma presented two months after the incident, disregarding standard treatment methods led the diagnosis to plausible entity of pseudo aneurysm. Standard protocol was followed. CT angiography was indicated and it confirmed the suspected diagnosis. Upon indication a treatment plan was established with correspondent angioembolization of the pathologic substrate. Pseudo aneurism of the superior gluteal artery should be considered as differential diagnosis for unexplained hematomas in the posterior pelvic region following a trauma regardless of its nature.

First Case of 2 Synchronous Gluteal Arteries Aneurysms Treated by Endovascular Plug Embolization: Case Report and Literature Review

INTRODUCTION

Gluteal artery aneurysms (GAAs) are rare, accounting for less than 1% of all arterial aneurysms. Most of them are post-traumatic in nature and involve the superior gluteal artery (SGA), while injuries of the inferior gluteal artery (IGA) have been reported less frequently. We report an unusual case of a patient with double saccular GAA of unknown etiology, involving both the SGA and IGA, successfully treated by endovascular embolization.

CASE REPORT

A 80-year-old man referred to our hospital complaining of the progressive onset of left buttock pain and swelling exacerbated by sitting position in the last 4 months. His past medical history was positive for hypertension, prostatic adenocarcinoma treated by brachytherapy, and endocarditis diagnosed about 30 years before and treated by cardiac surgical valve replacement; no history of trauma was reported. After ultrasonography was carried out, an enhanced computed tomography (CT) scan confirmed the presence of 2 large GAAs involving both the SGA and IGA, with maximum transverse diameter of 38 and 84 mm, respectively. The patient was referred for endovascular treatment after informed consent was provided. After sequential selective catheterization of SGA and IGA, 3 Amplatzer Plugs II (St. Jude Medical, Zaventem, Belgium) were deployed inside the aneurysms. Postoperative course was uneventful as buttock pain completely disappeared on the second postoperative day. The patient was discharged to home on the third postoperative day. One-month CT scan confirmed the complete thrombosis of the aneurysms without any endoleak.

CONCLUSIONS

GAAs represent a rare pathology, and for that reason, the correct timing and choice of treatment are not clearly defined. Endovascular techniques are the first step in the approach to GAAs. In case of complex anatomy, GAAs embolization by the use of vascular plugs can be successfully performed.

Ruptured superior gluteal artery pseudoaneurysm with hemorrhagic shock: Case report

Pseudoaneurysm of the superior gluteal artery (SGA) is very rare and the most common causes are blunt or penetrating pelvic traumas. Although pseudoaneurysm can be asymptomatic at the time of initial trauma, it can be symptomatic weeks, months, even years after initial trauma. We present a case of a ruptured superior gluteal artery pseudoaneurysm with hemorrhagic shock twenty days after a bomb injury in the Syria civil war. In addition, we review the anatomy of the SGA, clinical presentation and pitfalls of pseudoaneurysm, and imaging and treatment options.

Three-year delayed presentation of femoral pseudoaneurysm after penetrating limb trauma

BACKGROUND

Delayed presentations of lower limb pseudoaneurysms secondary to penetrating trauma are particularly rare.

METHODS

After presentation of this rare case report, we review relevant published literature.

RESULTS

We report a rare case of a 55-year-old man with a progressively enlarging mass measuring 15 cm by 15 cm on his right anteromedial thigh 3 years after penetrating trauma. Computer tomography angiogram revealed this to be a large pseudoaneurysm supplied by a side branch artery from the right superficial femoral artery. Using an open approach, the pseudoanerysm was successfully repaired with the side branch oversewn, and the patient made a good recovery being discharged from hospital 4 days later.

CONCLUSIONS

Surgeons must retain pseudoaneurysm as a prominent differential for a patient presenting with a progressively enlarging, expansile mass of an extremity after penetrating trauma to ensure urgent investigation and prompt vascular intervention. Both open surgical ablation and endovascular embolization of pseudoaneurysms of the extremities are effective techniques with low rates of complications and morbidity reported in published literature.

Penetrating injury to the buttock: an update

Clinical research on penetrating injury to the buttock is sparse and largely limited to case reports and clinical series. The purpose of this paper is to provide a detailed overview of literature of the topic and to propose a basic algorithm for management of penetrating gluteal injuries (PGI). MEDLINE, EMBASE, Cochran, and CINAHL databases were employed. Thirty-seven papers were selected and retrieved for overview from 1,021 records. PGI accounts for 2-3 % of all penetrating injuries, with a mortality rate up to 4 %. Most haemodynamically stable patients will benefit from traditional wound care and selective non-operative management. When gluteal fascia injury is confirmed or suspected, a contrast-enhanced CT-scan provides the most accurate injury diagnosis. CT-scan-based angiography and endovascular interventions radically supplement assessment and management of patients with penetrating injury to the major buttock and adjacent extra-buttock arteries. Immediate life-saving damage-control surgery is indicated for patients with hypovolemic shock and signs of internal bleeding. A universal basic management algorithm is proposed. This overview shows that penetrating injury to the buttock should be regarded as a potential life-threatening injury, and therefore, patients with such injuries should be managed in trauma centres equipped with hybrid operating theatres for emergency endovascular and open surgery for multidisciplinary teams operating 24/7.

Delayed presentation and management of blunt traumatic inferior gluteal artery pseudoaneurysm with associated arteriovenous fistula

Disruption of arterial wall integrity as a result of trauma, iatrogeny, inflammation, or infection may result in pseudoaneurysm formation. Gluteal artery aneurysms are rare and represent less than 1% of all arterial aneurysms. Pseudoaneurysms of the inferior gluteal artery (IGA) following blunt trauma are exceptionally rare with only 6 reported cases in the English literature. We describe an 82-year-old female with a remote history of a fall presenting with an enlarging buttock mass. Imaging confirmed an IGA pseudoaneurysm with associated arteriovenous fistula that was successfully treated with endovascular embolization.

Analytical review of 664 cases of penetrating buttock trauma

A comprehensive review of data has not yet been provided as penetrating injury to the buttock is not a common condition accounting for 2-3% of all penetrating injuries. The aim of the study is to provide the as yet lacking analytical review of the literature on penetrating trauma to the buttock, with appraisal of characteristics, features, outcomes, and patterns of major injuries. Based on these results we will provide an algorithm. Using a set of terms we searched the databases Pub Med, EMBASE, Cochran, and CINAHL for articles published in English between 1970 and 2010. We analysed cumulative data from prospective and retrospective studies, and case reports. The literature search revealed 36 relevant articles containing data on 664 patients. There was no grade A evidence found. The injury population mostly consists of young males (95.4%) with a high proportion missile injury (75.9%). Bleeding was found to be the key problem which mostly occurs from internal injury and results in shock in 10%. Overall mortality is 2.9% with significant adverse impact of visceral or vascular injury and shock (P < 0.001). The major injury pattern significantly varies between shot and stab injury with small bowel, colon, or rectum injuries leading in shot wounds, whilst vascular injury leads in stab wounds (P < 0.01). Laparotomy was required in 26.9% of patients. Wound infection, sepsis or multiorgan failure, small bowel fistula, ileus, rebleeding, focal neurologic deficit, and urinary tract infection were the most common complications. Sharp differences in injury pattern endorse an algorithm for differential therapy of penetrating buttock trauma. In conclusion, penetrating buttock trauma should be regarded as a life-threatening injury with impact beyond the pelvis until proven otherwise.

Blunt injury to the inferior gluteal artery: case report of a rare "near miss" event

Traumatic injuries of the inferior gluteal artery are rare, the majority of which are aneurysms due to sharp or blunt trauma. We report the rare case of a "near miss" event of a patient with an acute hemorrhagic mass in the right buttock caused by blunt trauma to the inferior gluteal artery without "hard" clinical signs of vascular injury. Despite the unusual presentation, diffuse injury of the inferior gluteal artery branches was diagnosed by ultrasonography and angiography. This article highlights the importance of considering an arterial injury following blunt trauma to the buttock with subsequent pain and swelling. Appreciation of this rare injury pattern is necessary in order to facilitate rapid diagnosis and appropriate treatment.

The significance of penetrating gluteal injuries: an analysis of the Operation Iraqi Freedom experience

BACKGROUND

Although penetrating gluteal injuries rarely are life-threatening, the risk for concomitant injury to regional anatomic structures warrants additional evaluation. We analyzed factors affecting the management and outcomes of these injuries.

METHODS

Retrospective analysis of prospectively collected data from the 31st Combat Support Hospital during Operation Iraqi Freedom over a 16 month period.

RESULTS

From 3442 patients, 115 patients (3.3%) suffered penetrating gluteal injuries. They were predominately male (98%) with a mean injury severity score of 13. Mortality was 6% (n = 7). Primary mechanisms of injury were improvised explosive devices (41%) and gunshot wounds (59%). Associated injuries were present in 57% of patients [orthopedic (35%), abdominal (29%), rectal (25%), vascular (21%), genitourinary (14%), pulmonary (11%), sphincter (9%)]. Overall, 76% required surgical management, with 14% developing postoperative complications. In total, 27 patients (24%) required stoma placement. Gunshot wounds were associated with through and through injuries (43% vs 6%, p < 0.01), rectal injury (35% vs 11%, p < 0.05), and stoma placement (32% vs 11%, p < 0.05). Blast injuries were associated with a higher mean transfusion requirement (11 vs 6 units, p < 0.05), increased length of stay (14 vs 9 days, p < 0.05), and traumatic brain injury (24% vs 6%, p < 0.05). Independent predictors of a need for stoma placement were gunshot wounds (odds ratio = 10, p < 0.05) and injury severity score greater than 20 (odds ratio = 27, p < 0.01).

CONCLUSIONS

Penetrating gluteal injuries are associated with significant damage to local structures. Gunshot wounds carry a higher risk of injury to the rectum and stoma placement, whereas blast injuries are associated with less local injury and more multisystem trauma.

Inferior gluteal artery pseudoaneurysm mimicking gluteal abscess

We report a case of pseudoaneurysm of inferior gluteal artery initially diagnosed as gluteal abscess. Pseudoaneurysms of inferior gluteal artery are rare. High degree of clinical suspicion is required in a patient presenting with a post-traumatic swelling in the gluteal region. These aneurysms may present with very different clinical pictures. They can be diagnosed by Doppler ultrasound, computed tomography or magnetic resonance imaging. Mainstay of the diagnosis is by angiography and the preferred management with good clinical results is with angiographic embolisation.

Traumatic inferior gluteal artery pseudoaneurysm and arteriovenous fistula managed with emergency transcatheter embolization

We present a case of blunt trauma to the buttock resulting in an inferior gluteal artery pseudoaneurysm and arteriovenous fistula. The characteristic diagnostic features on CT angiography and digital subtraction angiography (DSA), along with the emergency percutaneous management of this traumatic vascular injury, are described. A review of the literature demonstrates inferior gluteal artery pseudoaneurysm is a rare condition, while successful treatment with glue embolization is previously unreported.

Pseudoaneurysm of the inferior gluteal artery following polytrauma: diverse presentation of a dangerous complication: a report of two cases

Gluteal artery aneurysms are rare, and the majority of them are pseudoaneurysms secondary to blunt or penetrating trauma. The superior gluteal artery is normally affected. Inferior gluteal artery pseudoaneurysms are uncommon, and review of the literature revealed only 10 cases in the last 30 years. The mainstay of diagnosis is angiography, but these aneurysms may not be visible on an aortic flush angiogram, and super selective angiography may be required to delineate the anatomy. Treatment is either by surgical therapy or minimally invasive techniques, such as embolization, during angiography. We report two cases of pseudoaneurysms of the inferior gluteal artery following pelvic and acetabular trauma, presenting very differently in time and clinical picture. A review of the relevant literature is also presented.

Encounters with pseudoaneurysms in orthopaedic practice

Thirteen pseudoaneurysms are presented of which five were caused as a complication of pin/wire placement of external fixators (one conventional and four Ilizarov frames). The most common symptom was the presence of profuse persistent bleeding from either the wound or the pin/wire site. In nine patients the pseudoaneurysm was directly caused by a fracture or subsequent fracture stabilisation. Pre-operative evaluation included radiography, arteriography, Doppler and computed tomography (CT) angiography. Depending on the site and size of the pseudoaneurysm management consisted of either ligation, resection and end-to-end anastamosis/vein grafting, lateral suture, endoaneurysmorrhaphy or selective embolisation.A high index of suspicion needs to be maintained following penetrating injury in the vicinity of a major vessel, particularly in the presence of persisting symptoms. External fixators are widely used to treat complex orthopaedic problems. The procedure is technically demanding, requiring a sound knowledge of cross-sectional limb anatomy. Injudicious use may result in potentially life/limb threatening complication of pseudoaneurysm.

Color doppler sonography in the follow-up of giant glutealaneurysm embolization

False aneurysm of the gluteal artery is uncommon and may develop secondary to penetrating gluteal injury or pelvic trauma. The use of color Doppler sonography may allow the initial diagnosis of gluteal pseudoaneurysms and provide information about the success of the interventional radiological procedures. In this study, color Doppler sonographic examination demonstrated the failure of the endovascular treatment of a giant superior gluteal artery pseudoaneurysm. The second intervention of super-selective coil embolization provided optimal thrombosis and eliminated the need for open surgery.

Posterior urethral disruption secondary to a penetrating gluteal injury

We report a case of a complete posterior urethral injury secondary to a penetrating gluteal injury. Posterior urethral injury usually occurs in male patients with pelvic trauma. The reported incidence of urethral injury with pelvic fracture ranges from 1.6% to 25% (mean 10%), with 66% of them being complete posterior urethral ruptures. Causes of posterior urethral disruptions include blunt trauma, such as occur in road traffic accidents or falls from heights, and high velocity penetrating and crush injuries. Penetrating gluteal injuries that cause posterior urethral damage are extremely rare. This report presents the first case of a complete urethral injury due to a gluteal stab wound. Furthermore, this case demonstrates that any sign of injury to the lower urinary tract, regardless of the cause or weapon implicated, warrants an immediate evaluation.

A rare form of burn injury sustained during defaecation

An unusual mechanism of burn injury during defaecation is described.

Coil embolization of a gluteal false aneurysm in a patient with Marfan syndrome

Gluteal aneurysms, whether true or false, are exceptional. They represent less than 1% of all aneurysms and develop within the superior or inferior gluteal arteries, being branches of the internal iliac artery. We report here the case of a 35-year-old patient with Marfan syndrome in whom annuloaortic ectasia and Barlow's disease with mitral valve insufficiency successively developed followed by a gluteal false aneurysm, which led us to investigate the etiologic mechanism of the patient's conditions. The gluteal aneurysm was successfully treated by selective embolization, which would appear to be the elective therapeutic approach for these lesions.

Abnormal extrapelvic course of the inferior gluteal artery

At its extrapelvic course the inferior gluteal a. is found to be strictly related to the sciatic n. This relationship has been described in a general way, emphasizing its medial localization in respect to the nerve. Clinicosurgical reports describe cases of aneurysms of the inferior gluteal a. on its extrapelvic course and subsequent compression at the nerve. In order to get further details on the relationship between these two structures, 80 gluteal regions from 40 cadavers of adult Brazilian individuals, 29 males and 11 females, were dissected. The inferior gluteal a. was found medial to the sciatic n. in 62 cases (77.5%); in the 18 remaining (22.5%) the trunk of the artery or one of its branches perforated the nerve. Of these, 14 (77.8%) were males and 4 (22.2%) females. This disposition was found 8 times (44.4%) on the right and 10 (55.6%) on the left side; was unilateral in 4 individuals (1 on the right and 3 on the left side) and bilateral in 7. The course of the inferior gluteal a. through the sciatic n. and/or the presence of aneurysms of this artery should be considered as a possible cause of nerve compression.

False aneurysm of the inferior gluteal artery following penetrating buttock trauma: case report and review of the literature

The case of a 28-year-old man who presented with a false aneurysm of the inferior gluteal artery 3 months after a penetrating wound to the buttock is reported. Percutaneous transcatheter embolization was unsuccessful. At operation, abdominal access was used for control, with a gluteal approach to provide exposure of the aneurysm. The presentation and management of patients with this pattern of injury are discussed, and the relevant literature reviewed.